Margaret McCartney: If this was cancer there’d be an outcry—but it’s mental health

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In her comment piece ‘Does mental health “first aid” help?’ Margaret McCartney cautions against a national public mental health campaign.

The campaign in question is at the very early stages of development by Public Health England, in consultation with academics, clinicians, patient and public representatives and NGOs. The campaign is primarily for the general adult population and those who might be concerned about someone close to them. It aims to support members of the public to better understand common mental health conditions and increase their knowledge and use of self-help activities that can improve their mental wellbeing and ability to support others. The campaign is not intended to replace treatment services for mental health conditions or more severe mental illnesses where NHS care is indicated.

Dr McCartney states “if this was cancer there would be an outcry”. Primary prevention and early intervention in physical health is well established, and similar principles can and should be applied to mental health. For many with emotional and mental health problems much can be done outside of or alongside treatment services. By supporting individuals to engage in evidence-based, peer to peer support and self-care the campaign should improve mental health and wellbeing.

Dr McCartney asserts that the Mental Health First Aid (MHFA) approach is an ‘evidence-free zone’. In a meta-analysis of interventions based on the full MHFA programme Hadlaczky et al.(2014) showed increased knowledge of mental health conditions , and to a lesser extent, fewer negative attitudes and more help-seeking behaviour amongst programme beneficiaries.

Whilst the campaign is informed by the MHFA approach, it draws on broader and emerging evidence of the effectiveness of population-based mental health campaigns in improving mental health literacy and promoting the adoption of self-help behaviours. Both the delivery method and content of the campaign will be informed by this. However pinning down what works and how it works in population campaigns is a recognised research challenge. We aspire to add to the evidence base, and so there will be a robust evaluation of the campaign. We will evaluate the impacts and how mental health and help-seeking are influenced by the campaign.

Dr McCartney is concerned that training interventions such as MHFA run the risk of over-diagnosis and medicalisation. Such claims are not made about cancer or heart disease and it is not clear why this should happen with mental health conditions. Our campaign will provide online support to individuals to enable them to take informed and constructive action to improve their mental health and act early to reduce the impact of problems for themselves and others.

We believe that the government’s focus on a broader approach to the population’s mental health is a welcome step-change. This includes work on improving mental health care services through the implementation of the Five Year Forward View for Mental Health, work on the national public mental health campaign, the joint Education and Health Green Paper on children and young people’s mental health, a refreshed focus on suicide prevention, targeting mental health in the workplace and strengthening action from all parts of government on mental health. We should celebrate the priority being given to mental health and at PHE we are confident that this will lead to improvements in the mental health of the population.

Dr. McCartney highlights the importance of not mistaking population based mental health interventions with the provision of safe and effective services. Continuing with her analogy, offering advice regarding safe alcohol consumption could be seen as an intervention to reduce the incidence of alcohol related cancer, but would not be accepted as an adequate service response to cancer. While many children and young people will have self limiting difficulties with their mental health, 10% will have a diagnosable mental illness which has an impact on their day to day life.

Child and Adolescent Mental Health Services (CAMHS) receives less than 50p for every £100 spent on the NHS in Scotland and the situation isn't much better in the rest of the UK. About 25% of those children and young people with a mental health disorder get access to CAMHS, with the remainder not having their needs recognised or being unable to gain timely access to services. Children with cancer may die if they don't receive services. Those with mental illness may also die, develop chronic health conditions, fail to form mutually rewarding relationships, achieve within education and employment, develop addictions, fall into the criminal justice system. There are effective treatments available, but insufficient resource to meet the need. Many will present in crisis to A and E which has been the focus of much attention recently. It seems a good time to allocate resources to what works, prevents further harm and achieves personal and economic benefit for our children.

It is very sad that the National Health Service mental health survey found that 26% of young women aged 16 to 24 years in England had mental health problems compared with 9.1% of young men.1 Between 2011 to 2014 the annual incidence of self-harm increased three times more in girls (37.4 per 10 000) than boys (12.3 per 10 000). The sharp 68% increase in girls aged 13-16, from 45.9 per 10 000 to 77.0 per 10 000.2 This may reflect an increased exposure to therapeutic or contraceptive progestogens .

It is very sad that progestogens use sharply increasing monoamine oxide enzyme activity in the endometrium, blood and brain, as we discovered in the 1960s which inevitably cause depression in many females. 3,4

It is very sad that the RCGP oral contraception (OC) study found suicide was the main cause of death in the main years of the study when most OC use was current or recent and over 60 conditions were increased in takers and ex-takers. Hospital admission for depression increased 3.61 times in ex-takers. Relative risks of attempted suicide were 1.42 in current users and 2.12 in former takers compared with never takers. 5

It is very sad that in a more recent Swedish study of a million women, progestin-only takers in all age groups had increased risks of antidepressant use but the highest risk was in 16 to19 year-olds. Combined hormonal contraceptives also increased antidepressants use in 16 to 19 year-olds.6

It is very sad that the almost universal use of depressive progestogen contraception has also led to an increased use of antidepressants during pregnancy. In turn, such medications increase a range of often very serious psychiatric illnesses in children.7

McCartney appears to consider that interventions without double blind placebo controlled randomised trials operate in an ‘evidence free zone’. She cites a cost of £15million for volunteers to learn mental health first aid skills, interestingly about the estimated annual UK cost of Citalopram for its unlicensed use in anxiety (it’s only licensed anxiety use is in panic attacks with or without agarophobia(1)).
Evidence enhances understanding so both are required for effective healthcare. As human beings we are restricted by our neurology and so subject to both Know-do-itis and No-do-encephalopathy described in the Christmas BMJ (2) and to which my rapid response was welcomed by a personal email from the author.
As a joint discoverer of BabyGaze, a simple intervention that is effective in Anxiety, safe in children and deliverable within 5 minutes (3) (4) I have been overwhelmed by the (sometimes frankly rude) opposition from the medical “Evidence Brigade” who demand the sort of data afforded and selectively published by big pharma then promulgated using foreign trips for opinion formers and M&S sandwiches for prescribers even though ‘Waiting for the results of randomised trials of public health interventions can cost hundreds of lives, especially in poor countries with great need and potential to benefit’. (5)
My colleague and I have offered free training to medical colleagues in this simple “Mental Health Fist Aid” intervention but it has been shunned by doctors for want of more evidence while being welcomed by the non-statutory sector to empower the effectiveness of front line care workers dealing with large numbers of people that doctors don’t have time to see.
If BabyGaze were a simple, cheap and rapid intervention being ignored for cancer there would be an outcry. But it’s mental health so let’s eat sandwiches and prescribe unlicensed drugs at vast expense instead.

In Scotland, there is a national resource housed by NHS24 - Living Life and Breathing Space. The former is a free phone service offering therapy (guided self-help and CBT) for anyone over 16 years of age with:
•low mood
•mild to moderate depression
•anxiety
Ideal for those in remote locations where local services are at a distance (I am currently on an Orkney Isle). However, the waiting time to assessment is 6 months and a further delay of six weeks to beginning therapy if accepted.
All that is left in the meantime is Breathing Space for those with more acute needs unsure where to turn to - to listen and offer information and advice. The service is open in the evenings and weekends when family, friends or GPs may be unavailable.

It isn't really good enough, is it? I await the reasons for such a wait - staff absence, recruitment difficulty, funding limits, whatever? Presumably the therapist could be anywhere in the world able to us a phone and be understood.

Spiritual intervention in mental health
Unfortunately, in her interesting column on mental health “first aid” Dr McCartney does not mention the role of spiritual interventions which have been shown to have positive effects in conditions such as: anxiety (1); depression (2); schizophrenia (3); eating disorders (4); and dementia (5).

To give a better perspective on the issue of investment of mental health inpatient care in NHS England, I offer the sobering data from the report from the King's Fund: NHS hospital bed numbers: past, present, future (ref 1)

"Between 1987/8 and 2016/17, the total number of NHS hospital beds fell by approximately 52.4 per cent – from 299,364 to 142,568"

"The largest percentage falls have occurred in overnight mental health and learning disability beds, which fell by 72.1 and 96.4 per cent respectively between 1987/8 and 2016/17." That's from 67,112 to 18,730 for inpatient mental health beds, according for 22..1% of all NHS England hospital bed in 1987/8 down to 13.4% in 2016/7 respectively.

Although it was asserted that this reduction "was underpinned by a policy shift to providing care for people with mental health problems and learning disabilities in the community rather than in institutional settings"

However I believe that this assertion grossly misrepresented the reasons for the decrease in mental health beds. I do not believed that the current mental health inpatient/community care strategy changed in the last decade but the mental health beds were cut by 40% from 26,929 in 2007/8 to 18,730 in 2016/7 (general acute beds fell by 17% in the same period by comparison).

This reduction coincided with the beginnings of the global financial crisis (GFC) and its legacy today, where even more people need help in this area.

This is not an organisation that considered the implication of cuts in inpatient resources; certainly not a rational decision by any NHS manager trying to improve hospital services and reducing overcrowding like some time-based target enthusiasts claimed these managers are doing.

With a lack of suitable inpatient beds and the near-impossibility of ward boarding in psychiatric units (unlike general acute wards) I suspect more people seeking urgent help ended up being shuffled to community services, when inpatient care may have been more appropriate.

Hence the promotion of mental health awareness and training amongst non-traditional care providers, it's another "healthcare on the cheap" initiative. It may address some of those in need but surely the loss of some 3 million bed days annually (compared to a decade ago) must mean something.

We are all under more stress and uncertainty than pre-GFC with the concurrent escalation of austerity measures, Brexit and security risk; surely the cutting of professional services must hurt somewhere.

Perhaps the politicians will only sit up and notice what's going on when something happens closer to home. Until then the NHS will continue to squeeze whatever remaining life out of inpatient mental health services.